Justia Insurance Law Opinion Summaries
Articles Posted in Insurance Law
DaVita, Inc. v. Marietta Memorial Hospital Employee Health Benefit Plan
Beginning in 2017, DaVita provided dialysis treatment to Patient A, who was diagnosed with end-stage renal disease (ESRD). Patient A assigned his insurance rights to DaVita. Through August 2018, the costs of Patient A’s dialysis were reimbursed by the Employee Health Benefit Plan, governed by the Employee Retirement Income Security Act (ERISA), at its bottom tier, which applied to providers who are “out-of-network.” All dialysis providers were out-of-network. While most out-of-network providers are reimbursed in the bottom tier based on a “reasonable and customary” fee as understood in the healthcare industry, dialysis providers are subject to an “alternative basis for payment”; the Plan reimburses at 87.5% of the Medicare rate. Patient A was exposed to higher copayments, coinsurance amounts, and deductibles and was allegedly at risk of liability for the balance of what was not reimbursed . The Plan identified dialysis as subject to heightened scrutiny, which allegedly incentivizes dialysis patients to switch to Medicare. Patient A switched to Medicare. DaVita and Patient A sued, alleging that the Plan treats dialysis providers differently from other medical providers in violation of the Medicare Secondary Payer Act (MSPA) and ERISA.
The Sixth Circuit reversed, in part, the dismissal of the claims. A conditional payment by Medicare is required as a precondition to suing under the MSPA’s private cause of action; the complaint sufficiently alleges such a payment. DaVita plausibly alleged that the Plan violates the nondifferentiation provision of the MSPA, resulting in denials of benefits and unlawful discrimination under ERISA. View "DaVita, Inc. v. Marietta Memorial Hospital Employee Health Benefit Plan" on Justia Law
Downing v. Country Life Insurance Company
In October 2015, Amy Downing purchased a life insurance policy from Country Life Insurance Company. She purchased both an “executive whole life” policy that would pay a flat amount of $500,000 to her beneficiaries upon her death and a “Paid-Up Additions Rider” (PUAR) that provided an additional death benefit and an investment opportunity. Although Amy's father Tom worked for Country, another employee, Robert Sullivan, met with Amy and Tom to describe the terms of the policy. Amy asked Sullivan why she needed one and a half million dollars in insurance coverage because it was a larger benefit than she expected to need and it required higher yearly premiums. Sullivan explained that although she might not need the large death benefit, the structure of the PUAR provided an investment opportunity because it maximized the policy’s cash value. Sullivan later testified that he never represented to Amy that the death benefit associated with the PUAR was a flat amount. After paying the premiums for a year, Amy informed her parents that she intended to abandon the policy and withdraw its existing cash value. Her mother Kathleen decided to look into the policy as an investment. Kathleen decided to take over payment of the premiums on Amy’s life insurance policy, including the PUAR, as an investment. With Tom’s assistance, Amy assigned her policy to Kathleen. Four months later, on January 27, 2017, Amy died in an accident. Her death occurred in the second year of her policy coverage. Country paid the death benefit of $500,000 on Amy’s whole life policy. Country also paid $108,855 on Amy’s PUAR. Kathleen sued, alleging that she was entitled to $1,095,741 on Amy’s PUAR, minus the $108,855 already paid. Judgment was rendered in favor of Country, and Kathleen appealed. The Alaska Supreme Court determined the superior court did not err in its interpretation of the insurance policy at issue, and affirmed the decision. View "Downing v. Country Life Insurance Company" on Justia Law
Glover v. Allstate Property & Casualty Insurance Co.
In this insurance dispute stemming from a fatal car collision, the Supreme Court vacated the judgment of the trial court granting summary judgment in favor of Insurer, holding that the decedent's estate was entitled to summary judgment on the issues of whether the decedent was an "insured person" and the availability of $25,000 in further UIM coverage under the decedent's parents' Allstate policy.Shelina Glover died in a car accident. The insurers of the two responsible drivers paid policy limits, and Glover's estate received separate settlements for underinsured-motorist (UIM) coverage from Glover's own carrier and from that of Glover's husband, who was driving the vehicle on the day of the accident. The Estate requested further UIM coverage under Glover's parents' Allstate policy. The trial court granted summary judgment for Allstate, concluding that the policy's offset and anti-stacking provisions barred the Estate from recovery because the amount the Estate received from other insurers exceeded the limits under the policy. The Supreme Court vacated the judgment, holding (1) Glover was an "insured person" under the policy; and (2) the Estate's UIM settlements were not offset against the policy's UMI limit, and therefore, the Estate had an additional $25,000 UIM coverage available to it under the Allstate policy. View "Glover v. Allstate Property & Casualty Insurance Co." on Justia Law
Dones v. Life Insurance Co. of North America
While employed by Alameda County and on a medical leave of absence, Johnson enrolled online in supplemental life insurance coverage under a LINA group insurance policy. She remained on leave on the policy’s effective date and died six months later, without returning to work. When her beneficiary claimed benefits, LINA denied coverage based on a policy provision stating the insurance would not become effective if the employee was not in “active service” on the effective date. Johnson’s beneficiary sued for breach of contract, arguing that LINA and the county waived or were estopped from asserting the active service precondition.The court of appeal affirmed the dismissal of Alameda County but reversed the dismissal of LINA. In determining the effect of preconditions to effective coverage, waiver and estoppel are questions of fact. There are factual questions as to what Johnson knew or should have known about the active service requirement and whether the conduct of LINA and the county supported a reasonable expectation that the supplemental insurance was in place and effective. It is not apparent that “active service” has a single unambiguous meaning such that Johnson necessarily must have known she was not in “active service” because she was on medical leave. If Johnson’s policy went into effect, LINA, not the county, is liable for improper denial of benefits. View "Dones v. Life Insurance Co. of North America" on Justia Law
Valencia v. Allstate Texas Lloyd’s
Plaintiff, a Texas resident, filed suit against Allstate Texas, a Texas entity, seeking damages for breach of contract and violations of the Texas Deceptive Trade Practices Act, the Texas Insurance Code, the Texas Business and Commerce Code, and the Texas Civil Practice and Remedies Code. Allstate Illinois, rather than Allstate Texas, answered the petition and removed the case to federal court on the basis of diversity jurisdiction under 28 U.S.C. 1332(a) and 1441(b).The Fifth Circuit reversed the district court's denial of plaintiff's motion to remand to state court, and remanded with instructions for the district court to remand to state court. The court held that Allstate Illinois lacked the authority to remove the suit to federal court and the district court did not have subject matter jurisdiction over the case when it denied plaintiff's motion to remand because the only parties to the case at the time of removal was plaintiff and Allstate Texas, both Texas residents. In this case, Allstate Illinois was not a defendant as originally filed and did not become a defendant through proper means. View "Valencia v. Allstate Texas Lloyd's" on Justia Law
Scottsdale Insurance Co. v. United Rentals, Inc.
In this insurance coverage dispute, the First Circuit vacated the decision of the district court holding that United Rentals, Inc. was entitled to defense costs from Scottsdale Insurance Company as an additional insured and that the Scottsdale policy afforded additional insured coverage to United Rentals for its direct and vicarious liability but that this coverage was excess above United Rentals' own coverage under its policies with ACE American Insurance Company, holding that the district court erred in part.Gomes Services, Inc. contracted with United Rentals to rent an electric boom lift. While operated by a Gomes employee, the lift struck and injured Guy Ayotte. Ayotte sued United Rentals and Gomes. At the time of the accident, Gomes was insured by Scottsdale under a policy that extended coverage to any party that Gomes was required by written contract to add as an "additional insured." United Rentals requested that Scottsdale defend and indemnify United Rentals. After the district court made its ruling both parties appealed. The First Circuit held (1) Scottsdale had a duty to indemnify United Rentals in the Ayotte action for both its direct and vicarious liability; and (2) United Rentals' relevant policies did not qualify as "valid and collectible insurance," and therefore, the Scottsdale policy afforded coverage to United Rentals. View "Scottsdale Insurance Co. v. United Rentals, Inc." on Justia Law
XL Insurance America, Inc., et al. v. Noranda Aluminum Holding Corporation
Following two operation-disabling accidents, Noranda Aluminum Holding Corporation, an insured aluminum-products manufacturer, whose “all-risks” property-insurance policy included business- interruption coverage, did not rebuild its damaged facility and consequently did not resume operations. Noranda and its insurers agreed that the failure to rebuild and resume operations did not negate the business-interruption coverage. But when Noranda submitted its business-interruption claim, the parties could not agree on how to calculate the Noranda's gross-earnings loss, which was the measure of the insurers’ liability under the relevant policy. After a seven-day trial, a jury found in favor of Noranda, and the insurers appealed. At trial, Noranda's damages expert employed a model that measured the insured’s gross-earnings loss by comparing the value of the insured’s production had the accident not occurred with the value of its production after the accidents had it repaired and resumed operations with due diligence. Although the parties disputed whether the insurers took issue with this methodology at trial in this appeal, the insurers contended that the model was inconsistent with the policy’s formula for calculating gross-earnings loss and that it grossly exaggerated the amount of the Noranda's claim. The insurers also challenged Noranda's expert’s factual assumptions and claimed he improperly included amounts that the insured had waived in an earlier property-damage settlement. The Delaware Supreme Court concluded Noranda's expert's damages model was consistent with the relevant policy provisions, and that the trial court's determination that the factual assumptions made by the expert were sufficiently reliable for the jury to consider was not an abuse of discretion. Likewise, the Court held the insurers' claim that the earlier property-damage settlement precluded a portion of Noranda's recovery was without merit. Therefore, the Supreme Court affirmed. View "XL Insurance America, Inc., et al. v. Noranda Aluminum Holding Corporation" on Justia Law
Whiteside v. GEICO Indemnity Co.
The Eleventh Circuit certified three questions of insurance law to the Georgia Supreme Court: 1) When an insurer has no notice of a lawsuit against its insured, does O.C.G.A. 33-7-15 and a virtually identical insuring provision relieve the insurer of liability from a follow-on suit for bad faith? 2) If the notice provisions do not bar liability for a bad-faith claim, can an insured sue the insurer for bad faith when, after the insurer refused to settle but before judgment was entered against the insured, the insured lost coverage for failure to comply with a notice provision? 3) Does a party have the right to contest actual damages in a follow-on suit for bad faith if that party had no prior notice of or participation in the original suit? View "Whiteside v. GEICO Indemnity Co." on Justia Law
Isaacs v. Sentinal Insurance Co. Ltd.
The Supreme Court affirmed the opinion of the court of appeals affirming the trial court's summary judgment in favor of Insurer, holding that the trial court did not err in finding that Plaintiff did not qualify as an insured under the facts of this case.Plaintiff was riding his bicycle when he was struck by a truck. The driver of the truck was an underinsured motorist (UIM). Plaintiff filed claims for UIM coverage under the commercial insurance policy that covered vehicles owned by and used in the court of business at Plaintiff's law firm. Insurer denied the UIM claims under its commercial policy. Plaintiff then filed a motion for declaratory judgment asking the trial court to declare that Insurer was obligated to provide UIM benefits. The trial court granted summary judgment in favor of Insurer, and the court of appeals affirmed. The Supreme Court affirmed, holding that the trial court correctly found there were no issues as to any material fact and that Insurer was entitled to judgment as a matter of law. View "Isaacs v. Sentinal Insurance Co. Ltd." on Justia Law
Posted in:
Insurance Law, Kentucky Supreme Court
Metzger v. Auto-Owners Insurance Co.
The Supreme Court affirmed the decision of the court of appeals affirming the ruling of the trial court granting summary judgment for Insurer on Plaintiff's action seeking a declaration that Insurer was obligated to prove underinsured motorist (UIM) benefits under the terms of a commercial policy, holding that Plaintiff was not covered under the terms of the commercial UIM policy in this case.Plaintiff was a member of an LLC that bought a commercial automobile insurance policy from Insurer. Insurer included UIM coverage for the LLC's vehicles. Plaintiff was walking through the parking lot of a store where she had just purchased items for the LLC and was struck by an automobile. The driver of the vehicle was an underinsured motorist. Plaintiff submitted a UIM claim to Insurer. After Insurer denied the claim Plaintiff filed this declaratory action. The trial court granted summary judgment for Insurer, and the court of appeals affirmed. The Supreme Court affirmed, holding that the trial court correctly found there were no issues as to any material fact and that Insurer was entitled to judgment as a matter of law. View "Metzger v. Auto-Owners Insurance Co." on Justia Law
